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Home My Public Portal About5711 RIO HONDO AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ~7 ❑ Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM FEE �./ LOCALITY Date Applicant 11T WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER . SHOWER 14 / �t7 (This section need not be completed if the work involved by MAIL (� the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS —43 I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY_J_ TEL. NO. so as to become subject to the Workers'Compensation Laws. �r( � DISHWASHER CONTRACTOR _l Date /L/yApplicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS 7s y /� 7 �C-r ,e �45 Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITYkk/ TEL. NO.�`a�� Compensation provisions of the Labor Code, you must forth- �1 ✓1 G�, LAWN SPRINKLER SYSTEM ' with comply with such provisions or this permit shall be STATE —+ LIC. deemed revoked. WATER HEATER LICENSE NO.3'107 ,eY5 CLASS (� ✓` LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS i (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL a f �` _ — DATE VALIDATION O License Number� 0 �J Lic. Class �� 4 V r �4 (� FINAL � Contractor� Cy �1 , K Date 7 BY i 0 f- ❑ V I am exempt under Sec. WO. B.&P.C. for this reason _ H Plan check fee ? ate:_ � � ` Signature ��(7__ PLUMBING PERMIT ISSUING FEE$ ,.�YY� TOTAL FEE Z` Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , 7044, Business and Professions Code), CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the ► above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. �L9 A ��/�` �`` SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date / �• WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified co there f (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑oliEy No. Company E26/1LI Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) 10 Certified copy is filed with the c my buil g inspec- ADDRESS J / Bon department. NUMBER FIXTURE OR ITEM Ca) FEE LOCALITY Date dnnQ;t 4F>y Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER (This section need not be completed if the work involved by SHOWER the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CIT TEL. NO so as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY jJ,/ TEL. NO..- f_ > LAWN SPRINKLER SYSTEM Zv with comply with such provisions or this permit shall be STATE deemed revoked. WATER HEATER J LICENSE NO. ...3 Ali , CLASS t LICENSED CONTRACTORS DECLARATION DISTRICT NO. ESSED BY GAS SYSTEM OUTLETS - I hereby affirm that I am licensed under provisions of Chapter 9 ^ { (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL �-- DATE S 'Z� - V LIDATION License Numbeti /�C/ Lic. Class �'_� �p �'J S (/ / Date !Td�D 7 BY�AL Q Contractor ~ I am exempt under Sec. t3. alt: B.&P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE L> Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Addre s I certify that have read this application and state that the ► above infor, at is correct. agree to comply with all County ordinance and State laws regulating Plumbing, and hereby outhorizV representativ s of this County to enter upon the above- entione prty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of r ittee Date